Hello everyone,
Thank you to all who attended the journal club on October 6th. A great discussion was had with many interesting thoughts and ideas put forth. Below is a summary of the key points we discussed at the meeting. Click here to download a pdf of the paper.
Last week we reviewed a national study by Hayden et al. (2010) that explores the idea of replacing clinical hours with high-fidelity simulation in prelicensure nursing education due to concerns regarding shortages of clinical placements. While we currently have more patients and nurses in hospitals than ever before, attendees agreed that the growing number of nursing schools and seats available has caused competition for clinical placements. While simulation may offer a range of benefits and serve as an effective clinical educational tool, how much of it is really appropriate in replacing actual practice?
The study looked at both ADN and BSN degree programs in the USA. While the ADN curriculum is quite different and geared primarily towards individuals who are perceived as not wishing to progress to higher level nursing, the same outcomes were used for both. Outcome measures consisted of six different performance related scoring tools, including the ATI RN Comprehensive Predictor® 2010 (Assessment Technologies Institute, LLC) and the National Council Licensure Examination (NCLEX®). Looking at these two tools, the group concluded that there is a significant amount of overlap between them, and many are in fact measuring the same outcomes. This makes it difficult to identify what each tool is specifically measuring, and to consider whether they have measured additional criteria that do not in fact pertain to the study.
The study was a longitudinal randomized trial, where 25% of traditional clinical hours were replaced by simulation in one group, and 50% in the other, and a control with less than 10% simulation. The study revealed that there were no significant differences in the outcomes assessed between the two groups. A significant problem, however, was the multitude of confounding variables associated with the study (and with trials in educational research in general). The inclusion of two entirely different programs with very differing curricula was seen as problematic. Furthermore, despite attempts at standardizing the intervention, the two increased-simulation groups appear to be using different simulations, chosen based on what was deemed appropriate for their respective curricula. These variables make it difficult to determine the factors that truly contributed to the outcome. Additionally, blinding was not feasible in this type of study, causing further skepticism with regards to the findings.
Throughout the meeting, there was certainly debate regarding the value of simulation. One attendee suggested that whilst some clinical hours cannot be replaced, there are instances where clinical experience may be minimally engaging, such as observational activities, where simulation may, in fac,t be more useful. Additionally, simulation allows the instructor to target very specific scenarios that students may not gain exposure to in clinical. Another argued that the current level of simulation fidelity lacks many of the real-world environmental cues that present in clinical, such as cyanosis and cool, clammy skin; as indicators that help guide nursing care. Additionally, it was noted that part of the value of clinical experience is immersion and socialization in the multiprofessional team in an actual clinical setting. Much of the learning that occurs there takes place in clinical practice occurs outside of focused clinical cases. This will be missed in any simulated activity.
Overall, most agreed that there was certainly value to simulation exercises, however, clinical hours are invaluable and ultimately should not be replaced.
Below are the presentation slides used throughout the discussion:
EKM Journal Club Slides: Replacing Clinical with Simulation
Thank you to all who attended and contributed to the discussion. Our next EKM Journal Club will be held on Monday, November 3rd from 12:00-1:00 in room T220. Hope to see you there!
